The importance of being present

Sometimes a simple gesture and a few well-placed words can signal presence. One day on rounds in the hospital, as we walked into the room, Laura Hogan, a nurse-practitioner on our palliative care team, said three words to the patient: “What beautiful flowers.” The patient looked at the flowers and smiled. The previous day the patient had had a biopsy that would let her know whether her cancer had progressed; she was still awaiting the results. We all feared that the news would not be good. Laura’s comment communicated that even in dire circumstances it is possible to see beauty and to honor those who loved and cared for the patient, that she was not alone. More often, though, presence is communicated nonverbally — a softness of gaze, a quality of touch, a handshake that is felt genuine rather than perfunctory, a gentle examination of a patient’s tender abdomen.

Presence is also “presentness” of time. When I feel that I’m being present while caring for patients, time seems to expand or stand still. Several years ago, I went to a jazz concert by Chick Corea’s group. During the opening piece, after each of the musicians had had a chance to improvise, the music reached a resting point, a silence that probably only lasted two seconds. Even though the concert was in a three-thousand-seat auditorium, everyone seemed to feel the same sense of intimacy and connection in that silence. That moment had an exquisite spaciousness, as if the outside world had ceased to exist, a spaciousness that resolved only when the musicians simultaneously struck a chord marking a new section of the music. Think of speeches by Martin Luther King Jr. or Mahatma Gandhi. You are captivated, entranced, transported, and time seems to stop or ceases altogether.

When physicians are being present, patients feel that spaciousness. I remember the first time I felt it as a patient. I was in my late teens and had not been feeling well for over a month; I was weak, tired, and feverish, with a sore throat, headaches, and no energy. I would get better for a while, then it would come back. I had recently graduated from my pediatrician to a new “adult” doctor, whom I did not know well. He was thorough and gentle as he examined my ears, throat, neck, chest, and abdomen. I presume that the physical examination was normal and uninformative; it confirmed a diagnosis that he had already made.

Time seemed to stand still. I was worried; he was imperturbably calm. He was much older than I, but that didn’t seem to matter; he was warm, and his eyes had a softness. I felt that he understood me and my situation, and the distance between us seemed to dissolve. He said that he’d seen this cluster of symptoms, which was probably a lingering virus, and that time would heal. He ordered a blood test just to make sure. That’s all I needed.

This was the first time I felt understood and cared for — honored and respected — by a physician. I carried his presence with me after I went home and found his virtual presence quietly reassuring; I was not worrying alone. A couple of weeks later, I began to feel more myself. His image came to me years later as I was contemplating going to medical school and later during the dark moments when I wondered whether memorizing names of bacteria and reciting differential diagnoses was all that it could be about.

Later still, I discovered that I could be present in that way — and share my presence with patients. I had a new patient in my practice — Haqim, sixteen years old, muscular, confident, and robust. He had acne on his back and shoulders. He asked question after question — about hormones and how they affect the skin (and why they make people unattractive), how each medication worked, whether he could try two of them at the same time, and how long it would take for the bumps and cysts to go away.

He was worried — very worried. I listened, without interpreting or reflecting — I just listened. I explained that time would heal, with the help of a few creams and pills. After a few more questions about how the pills actually worked, he relaxed and even smiled. We spent the remaining five minutes of the fifteen-minute visit talking about his family. Since then Haqim has mentioned to me on more than one occasion that he wants to become a doctor.